Harness the MDS for dementia care

Mr. J, an Alzheimer's resident in the nursing home's memory care unit, needs assistance with activities of daily living (ADLs). As his dementia has progressed, it has become difficult for the nurse aides to assist him. He is gradually becoming more incontinent, has angry outbursts and wanders into other residents' rooms. Showering is a battle. The nursing assistants want to meet his needs, but it is not easy.

Unfortunately, dementia care service is complex and includes pressure to comply with federal regulations. In the interpretive guidelines for care of residents with dementia, the Centers for Medicare & Medicaid Services instructs surveyors to determine whether the facility staff are using the care plan to provide the resident with the necessary care and services, are evaluating the resident's outcomes and changing the interventions as needed. The guidelines state: "This should be done in accordance with the resident's customary daily routine." This survey process hones in on the need for facility leaders to foster a strong care delivery system.

Mr. J's customary daily routine is changing as his Alzheimer's disease progresses. This makes meeting his needs, which can change from shift to shift, and complying with ongoing regulations challenging.

One of the tools available to assist facility staff with meeting Mr. J's needs while complying with regulations is the federally mandated minimum data set (MDS). The MDS involves a skilled nurse capturing the resident's ADLs (in section G), using the care area assessment (CAA) process to conduct a critical analysis of Mr. J's ADL care needs and developing a care plan. The MDS process is designed to help facility staff assess and address a resident's changing needs as they occur.

Identifying the Alzheimer's disease stage

The Centers for Disease Control and Prevention estimates more than 48 percent of residents in nursing homes have Alzheimer's disease. The Fisher Center for Alzheimer's Research describes the mental and physical manifestations of the seven stages of Alzheimer's as follows:

Stage 1: Normal. Free from any behavioral or mood changes.

Stage 2: Normal-aged forgetfulness. Subjective complaints of cognitive and/or functional difficulties (e.g., not remembering names as well as before).

Stage 3: Mild cognitive impairment. Very subtle memory problems, usually only detected by close friends and loved ones.

Stage 4: Mild Alzheimer's disease. Decreased ability to manage complex ADLs such as finances, preparing meals for guests, or paying bills.

Stage 5: Moderate Alzheimer's disease. Independent community living becomes difficult. The resident may choose the wrong clothes for the weather or not change clothes for days. The resident may recall important information on some occasions but not others.

Stage 6: Moderate to severe Alzheimer's disease (stages 6a–6e). At this stage, the resident needs help to select and put on clothing correctly (6a), loses the ability to bathe without assistance (6b), needs help in the bathroom (6c), becomes bladder incontinent (6d) and develops bowel incontinence (6e). A sign that this stage is coming to an end is stuttering, using meaningless words and turning inward (reduced speech).

Stage 7: Severe Alzheimer's disease (stages 7a–7f). In this final phase, the resident needs continuous care with ADLs. This resident may use no more than six intelligible words (7a). Without good care, the resident loses the ability to walk (7c) and may later need the support of positioning devices in order to sit (7d). Finally, the resident will be unable to hold up his or her head (7f).

Often, residents in memory care units are in the later stages of the disease process (moderate to severe). But with facilities being used by greater numbers of short-term rehabilitation residents and short-term early Alzheimer's residents (as respite care), nursing facility staff are treating residents at all stages of the disease. The MDS assessment process is one constant for all nursing home residents, whether for short-term rehab or long-term memory care.

Using the MDS process

Accurate completion of the MDS can help staff identify a resident's current level of deficits and needed support, at all stages in the disease. Consider Mr. J’s need for toileting assistance (6a) and his development of bladder incontinence (6d) and bowel incontinence (6e). The MDS can assist in identifying these stages in section G (item G0110I), section H (for toileting programs and continence assessment), and section E (for behavioral expression).

The Fisher Center for Alzheimer's Research has aptly identified superb care as making a huge difference in the quality of life for a resident with Alzheimer’s. And superb care requires effective resident-centered care planning.

However, there are pitfalls to effectively capturing Mr. J's ADLs on the MDS. The documentation required for the MDS process often starts with nursing assistant charting. It can be difficult to capture the accurate number of episodes of resident self-performance, staff assistance and incontinence from the charting.

Both sections G and H of the MDS require scoring based on episodes. If a nursing assistant charts only once a shift, the number of care-level episodes that occurred during the shift may not be identified properly. I have audited medical records that reveal electronic shift charting occurring at the start of the shift, before care has even begun. In paper-based charting systems, nursing assistants often copy one another's charting.

The result of inaccurate ADL charting and assessment for residents like Mr. J is a lack of recognition of subtle progression in the dementia stages. The MDS assessment process can help identify whether a decline was avoidable or simply part of the disease. During the MDS assessment process, the nurse should not only evaluate the charting, but also interview direct-care staff on each shift and interview/observe the resident.

Another benefit of the MDS process is the Significant Change in Status Assessment (SCSA). As Mr. J's condition deteriorates, an SCSA should be triggered at appropriate points in his disease process. A reassessment of his condition can result in improved care-plan interventions to meet his changing needs. A change in which Mr. J requires physical help rather than simply cueing in two areas of ADLs would necessitate an SCSA. During the assessment process, the nurse uses the MDS and CAA processes to identify Mr. J's individual deficits and develop appropriate care plan interventions.

Nursing home residents with Alzheimer's disease benefit greatly when staff utilize the federally mandated MDS process effectively. It may not be magic, but it can move you closer to quality care.

Judi Kulus will be presenting at the Memory Care Forum May 23-24, 2016, in Philadelphia.

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